For almost 100 years, the ACLU has worked to defend and preserve the individual rights and liberties guaranteed by the Constitution and laws of the United States.

Another young girl has been thrust into the center of a struggle with the federal government. We have her back – and I hope I can count on you to join the fight.

Last week, Border Patrol agents stalked 10-year-old Rosa Maria as she went to the hospital for gall bladder surgery. They camped outside her hospital room, waiting for Rosa Maria – who has cerebral palsy – to regain consciousness. Then they locked her in a detention center, 150 miles away from her family.

First Jane Doe, now Rosa Maria. This cruel and unconstitutional treatment of immigrant girls must stop. We’re ready to sue if the government doesn’t release her by 3pm EDT TODAY. But first we need your help:

Call the Office of Refugee Resettlement today and demand they release Rosa Maria Hernandez back to her family immediately.

The Office of Refugee Resettlement (ORR) had no legal authority to detain Rosa Maria, and her detention violates her constitutional rights to her parents’ care and support. We sent ORR a letter demanding they release Rosa Maria by 3pm EDT on Tuesday, October 31, 2017. If they don’t, then we’ll sue.

The public outcry in support of Jane Doe put ORR’s director, the rabidly anti-choice Scott Lloyd, on notice. We need to raise our voices again for Rosa Maria – and make sure we hold Lloyd accountable for his cruel and unconstitutional treatment of this girl, too.

Please make a call right away demanding the Office of Refugee and Resettlement release 10-year-old Rosa Maria back into the care of her family today.

This elementary school student needs to be recovering from surgery at home with the family that loves her, not jailed in a detention center.

Thanks for raising your voice to protect Rosa Maria and all vulnerable youth.

Michael Tan
ACLU attorney, fighting for immigrants’ rights

P.S. Already made your call? Please forward this email to three friends so we can flood ORR with phone calls.

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Patients With Chronic Pain Are Twice as Likely to Attempt Suicide

http://www.clinicalpainadvisor.com/chronic-pain/suicide-attempts-in-chronic-pain/article/697827/

LAS VEGAS — Patients with chronic pain are vulnerable to depression and may present with higher risk for suicide, according to findings from a literature review presented at PAINWeek 2017.¹ Integration of mental health assessment during the diagnosis and treatment of chronic pain may be clinically important for reducing risk in this patient population. Unfortunately most chronic pain conditions are related to overweight, treat and prevent most of them with meticore.

In 2014, suicide ranked as the 10th most frequent cause of death.² Patients with chronic pain are twice as likely to attempt suicide compared with those without chronic pain, an action generally caused by a myriad of associated psychological, physical, and social factors.³ A questionnaire survey of 1512 patients with chronic pain found that 32% reported suicide ideation in some degree.⁴ 

Chronic pain affects cognition and behavior and may ultimately lead to social isolation, contributing to depression.⁵ Risk factors and predisposing factors associated with suicidal risk in patients with chronic pain include biochemical and neurochemical influences, genetics, psychosocial events, and environment, according to the researchers’ findings.

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Investor group presses U.S. drug companies on opioid controls

http://www.reuters.com/article/us-drugs-opioids-investors/investor-group-presses-u-s-drug-companies-on-opioid-controls-idUSKBN1CZ15D

BOSTON (Reuters) – U.S. shareholder activists are addressing a soaring death toll from opioid drug abuse, asking companies that make and distribute the painkillers to review the risks their businesses could face from their role in the sector.

Leaders of a 30-fund group that includes state pension officials and religious and labor organizations plan to reveal on Monday they have begun filing shareholder resolutions at 10 companies, including distributors AmerisourceBergen Corp (ABC.N) and Cardinal Health Inc (CAH.N) and manufacturers Johnson & Johnson (JNJ.N) and Insys Therapeutics (INSY.O).

In resolutions aimed at annual shareholder meetings to be held in 2018 and in letters to the companies, activists are urging independent directors to review and report on how the boards are managing the legal, financial and reputational risks their enterprises face from their involvement with opioids.

They also seek corporate-governance reforms such as allowing more grounds to claw back pay from executives who inappropriately promote the drugs, or creating independent board chairs to provide better oversight.

Representatives of Cardinal and Insys did not immediately respond to requests for comment.

Johnson & Johnson spokesman Ernie Knewitz said the company was preparing a response to the investors, and that the company had acted responsibly.

“Opioid abuse is a serious public health issue that must be addressed, and doing so will require collaboration among many stakeholders, and our company is committed to working with federal, state and local officials to help find meaningful solutions,” he said in an emailed statement.

In a statement emailed by AmerisourceBergen spokeswoman Keri Mattox, the company said it “welcomes a productive dialogue with all shareholders. The issue of opioid abuse is a complex one that spans the full healthcare spectrum, including manufacturers, wholesalers, insurers, prescribers, pharmacists and regulatory and enforcement agencies.”

The statement said the company worked closely with officials “to combat drug diversion while supporting appropriate access to medications.”

At an annual meeting on Nov. 8, Cardinal Health will face a resolution calling for an independent board chair in order to improve oversight.

“These considerations are especially critical at Cardinal given the potential reputational, legal and regulatory risks Cardinal faces over its role in the nation’s opioid epidemic, including its history of compliance challenges concerning the distribution of controlled substances,” the resolution’s sponsors, including the International Brotherhood of Teamsters, said in a supporting statement. The statement cited Cardinal’s payment of tens of millions of dollar to settle various federal and state charges related to opioids.

In a securities filing, Cardinal calls the change unnecessary, noting it already has an independent lead director and “state-of-the-art controls” over its pain medications.

Officials at all levels of government in the United States are struggling to respond to a surge in deaths from opioid abuse, which hit 33,000 in 2015, the last year for which there is complete federal data.

In many cases patients prescribed opioid painkillers become addicted to them and then move on to acquiring the drugs illegally, or turn to heroin or fentanyl, a highly potent synthetic opiate.

U.S. President Donald Trump on Thursday declared the opioid epidemic a national public health emergency.

State attorneys general have also taken on opioid manufacturers, with lawsuits charging that deceptive marketing practices helped fuel an epidemic of abuse. Federal prosecutors on Thursday charged the founder of Insys, John Kapoor, with participating in a scheme to bribe doctors to prescribe a particularly potent opioid.

A lawyer for Kapoor said in a statement that Kapoor is innocent and will fight the charges.

Shareholder activists said healthcare providers may have underestimated how addictive the drugs were, but said the crisis points to a need for stronger oversight within drugmakers.

“We believe these companies have played an important role in this epidemic,” said Donna Meyer, director of shareholder advocacy for Mercy Investment Services, an investment fund for Roman Catholic nuns. It is leading the resolutions push, along with the UAW Retiree Medical Benefits Trust, which oversees benefits for about 700,000 retirees of the United Auto Workers.

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Maternal Use of Acetaminophen Linked to ADHD in Kids

https://www.medscape.com/viewarticle/887773

A pregnant woman’s use of acetaminophen may be associated with an increase in her child’s risk for attention-deficit/hyperactivity disorder (ADHD), the authors of a large, prospective study report.

“[L]ong-term acetaminophen use during pregnancy is related to more than a twofold increase in risk for offspring ADHD,” after adjusting for genetic risk factors, indications for the mother’s acetaminophen use, use of the drug before pregnancy, and other potential confounders, lead author Eivind Ystrom, PhD, and colleagues write in an article published online today and in the November issue of Pediatrics.

Conversely, use of acetaminophen for less than 8 days during pregnancy was associated with a decrease in ADHD risk, suggesting its antipyretic effect “could be beneficial with regard to fetal development,” the authors add.

In an accompanying commentary, Mark L. Wolraich, MD, who was not involved in the study, cautions that these findings do not establish a causal relationship between prenatal acetaminophen exposure and ADHD risk, “but they do suggest the possibility and raise the need for further study and more cautious consideration of acetaminophen use during pregnancy.”

It is estimated that approximately 65% to 70% of pregnant women in the United States and approximately 50% to 60% of pregnant women in western and northern Europe use acetaminophen.

Data on More Than 100,000 Children

For the current study, Dr. Ystrom, from the Norwegian Institute of Public Health, Oslo, and colleagues analyzed data from the Norwegian Mother and Child Cohort Study, which includes information on 114,744 children born between 1999 and 2009, as well as on 95,242 mothers and 75,217 fathers throughout Norway.

Mothers and fathers alike completed questionnaires at 18 weeks of gestation. The mothers also filled out questionnaires later in pregnancy, after delivery, and when their children reached 6 months, 1.5 years, and 3 years of age. The researchers obtained information on ADHD diagnoses from records maintained by the Norwegian Patient Registry.

The parents’ questionnaires included questions about their acetaminophen use. To control for potential confounders, the mothers also answered questions regarding various medical conditions for which acetaminophen was indicated, as well as the duration of their acetaminophen use. Their children were followed to the time of their ADHD diagnosis or until December 31, 2014.

The final sample consisted of 112,973 children and their parents. Of those children, 2246 (2%) were diagnosed with ADHD, and 52,707 (46.7%) mothers reported some acetaminophen use during pregnancy. Compared with no acetaminophen exposure, the unadjusted hazard rate (HR) of ADHD in children after 1, 2, or 3 trimesters of prepartum exposure was 17%, 39%, and 46%, respectively.

Duration Makes a Difference

When the authors adjusted for parental ADHD symptoms, the risk associated with acetaminophen use declined slightly, from an HR of 1.26 in the unadjusted model to 1.20 (95% confidence interval [CI], 1.09 – 1.32). However, when calculated by amount of exposure, the rate rose from 1.13 (95% CI, 1.01 – 1.27) for any one trimester to 1.32 (95% CI, 1.16 – 1.50) for any 2 trimesters, and to 1.34 (95% CI, 1.05 – 1.71) for all three trimesters.

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http://woodtv.com/2017/10/29/pain-relief-denied-insurer-stops-covering-popular-therapy/

GRAND RAPIDS, Mich. (WOOD) — Alex Ostrowski has worked hard to control her pain. Now, she fears it will control her again.

“I would describe where I was at 10 years ago as a fog,” Ostrowski said.

Ostrowski, now 30, was first prescribed opioids at age 14.

“You’re controlling your pain, but at the price of normal interaction, at the price of normal quality of life,” she explained.

Ostrowski’s chronic back pain stems from injuries she suffered in a horrific accident on the Sparta lake where she grew up. Ostrowski was 12 years old when a boat ran over her Jet Ski on Camp Lake, pinning her body between its propeller and the wooden slats of the boat’s diving board.

“The propeller cut into the entire left side of my body, in to my stomach, into my intestines, completely crushed my hip and my pelvis,” Ostrowski said.

Incredibly, doctors were able to save not only her life, but also both of her legs. They used metal rods to rebuild her left hip and pelvis.

But the extensive physical trauma led to excruciating chronic back pain and years of overmedication on opioids.

“It was a dark place. It was a very dark place,” Ostrowski said of her years on painkillers.

PATIENT COVERAGE CUTS “TERRIFYING”

Six years ago, Ostrowski found Javery Pain Institute in Grand Rapids, which helped her get off high-dose opioids and find a procedure called facet joint injections that provided the pain relief she desperately sought. In that procedure, small amounts of anti-arthritic steroids — not opioids — are injected into the patient’s spinal joints.

“It’s given you your life back,” Dr. Keith Javery, who is board-certified in anesthesiology and pain management, said during a recent consultation with Ostrowski at the clinic on Kenmoore Drive SE. “With those injections, you were able not only to get back to work, but get into a supervisory role.

“It kills me that the insurance company is no longer allowing us to do those therapeutic facet injections,” Javery said.

Ostrowski is trying alternative procedures, but so far has nothing has worked as well as the facet injections.

“I feel like I’m being punished because I don’t want to take pain medications and that seems so backwards,” she said. “It’s terrifying. I feel almost pushed back into that place by them denying coverage of this procedure. They leave you no other options.”

According to Javery, new restrictions on the kinds of injections and the number of procedures allowed per visit are hurting hundreds of patients at his clinic alone.

DOCTOR: PAIN TREATMENTS ‘LITERALLY SAVE LIVES’

In late 2016, Blue Care Network, one of Michigan’s biggest insurers and a subsidiary of Blue Cross Blue Shield of Michigan, stopped covering the commonly used spinal joint injections for long-term pain relief — the kind of treatment Ostrowski was getting.

The change came after the insurer hired an outside benefits management company, South Carolina-based eviCore Healthcare, to handle interventional pain claims for members.

EviCore considers therapeutic facet injections “experimental, investigational or unproven,” according to its clinical guidelines.

>>PDF: eviCore clinical guidelines

“All these things that we can do to reduce the need (for opioids) are being rapidly in real time denied and not authorized by insurance companies that have been authorizing these for decades,” Javery explained.

“These treatments literally save lives,” he argued.

BLUE CARE NETWORK: NO HIGH-LEVEL EVIDENCE-BASED SUPPORT FOR INJECTION

Blue Care Network confirmed to Target 8 that its coverage guidelines on facet joint injections have changed.

“Blue Care Network’s current policies and coverage guidelines align with eviCore’s and are based on proven, clinical best practices,” Dr. Marc Keshishian of Blue Care Network wrote in an email to Target 8. “Our approach is to take responsible steps to eliminate unnecessary care and expenses in the health care system that drives up costs for our customers and members, by using clinically valid determinations that ensure our members get the most appropriate and effective care at the right time on their path to wellness.

“There’s no high-level evidence-based medicine supporting therapeutic facet joint injections,” Keshishian, the senior vice president and chief medical officer for Blue Care Network, continued.

Pain physicians themselves acknowledge there’s a lack of high-quality, large-sample studies on interventional pain procedures. They say that’s partially because it’s difficult to recruit subjects for double-blind pain studies in which some participants will receive placebos.

But Javery said he doesn’t need “high-level evidence” because he sees the results every day.

“The pain relief is drastic,” he said.

Many insurers still cover facet joint injections for long-term pain relief, though the number per year is limited, often to five sessions per region per year. Medicaid and Medicare are among those that cover the injections, though Michigan’s Medicare administrator told Target 8 supporting evidence for their use is “not strong” and that Medicare covers them simply because the procedures have been done for a long time.

It’s clear there’s no broad consensus across the health care industry on best practices for pain management.

In fact, Blue Care Network’s own medical director for behavioral health told Target 8 his experience supported the use of facet injections.

“Facet blocks have been around since I started practice,” Dr. William Beecroft of Blue Care Network said. “They’re very effective. They work very well with relatively low side effects, adverse reactions to them. There are some better procedures now looking at a treatment plan, but if they work for the individual and consistently work for that person, it’s illogical they would be stopped.”

Blue Care Network initially provided Beecroft for a sit-down interview with Target 8 because the insurer thought the story focused on opioids, not changes to pain treatment coverage, though Target 8 specified the latter in a prior email exchange.

In response to a list of questions Target 8 submitted after the interview with Beecroft, Blue Care Network said the concerns regarding coverage cuts “appears to be an isolated complaint by a specialist and members.”

The complaint is not isolated.

MICHIGAN PAIN CONSULTANTS: “PATIENTS FEEL TRAPPED”

Michigan Pain Consultants is also frustrated by the reductions in coverage.

“Patients feel trapped,” said Lisa Pearson, executive director of Michigan Pain Consultants, one of the state’s largest networks of clinics.

“Limited on the injections. Limited on the narcotics. High co-pays and deductibles for physician therapy and behavior therapy, both important to treating chronic pain in a comprehensive fashion,” she wrote in an email to Target 8.

Pearson said the biggest issue for patients is the reduction in what injections they are allowed to get and how often they can get them, especially with facets and epidurals.

“Patients with whom our physicians have worked for months or years to dial in the best pain relief possible with the fewest side effects are told that despite the fact that we document the injections wear off at week 7 or 8 or 9 are told that they have to wait another 3 or 4 or 5 weeks in severe pain before they get treatment. If we could magically make depomedrol (an anti-inflammatory steroid) last longer than it lasts, we’d do so,” Pearson said.

“What is the point of even having physicians, if the insurance companies and companies like eviCore ultimately override the physician’s decisions? This is an extremely dangerous path that we are going down,” Pearson argued.

EVICORE: GUIDELINES “GROUNDED IN STRONGEST EVIDENCE-BASED MEDICINE”  

For its part, eviCore told Target 8 in an email that its coverage guidelines are “grounded in the strongest evidence-based medicine published to date.”

“Pain complaints, most of which are attributed to musculoskeletal conditions, impact more than 116 million Americans annually, making it critical that we ensure these patients are receiving the type of evidence-based care that best positions them for successful outcomes,” wrote Robert W. Westergan, M.D., chief of musculoskeletal programs for eviCore.

“EviCore’s guidelines, first and foremost, reflect the most current, evidence-based criteria and peer-reviewed literature available. These guidelines are completely transparent and available for anyone to view,” Westergan wrote. “Our only goal is to ensure that the patient receives the most appropriate, evidence-based care for his or her situation. Evicore’s clinical reviews make determinations following the Evicore evidence-based clinical criteria, even if that results in a more expensive episode of care.”

PATIENT WILL ASK STATE TO REVERSE DENIAL 

Meanwhile, Alex Ostrowski is trying alternative treatments, though none have worked as well for her as facet joint injections did.

The newly married marketing manager can’t afford to pay out of pocket for the four times yearly injections. One series of the treatments (she gets several shots at a time) would cost her more than $800.

Her appeal to eviCore and Blue Care Network has been denied, but Ostrowski has every intention of asking the state to review her case.

Michigan’s Department of Insurance and Financial Services conducts external reviews of cases that qualify under the Patient’s Right to Independent Review Act. DIFS can reverse a denial and order an insurer to cover the denied treatment, medication or device.

Here are the outcomes from PRIRA reviews from DIFS 2016 annual report:

Health Benefit Claims

• New Requests for External Review: 887
• General Insurance: 576
• HMO/AFDS: 311

Commercial Insurers

• Number of Orders issued and the Carrier’s Position was Upheld: 222
• Numbers of Orders issued and the Carrier’s Position was Reversed: 78
• Cases Resolved before issuance of an Order: 56
• Not Accepted, Dismissed or Withdrawn: 193

Health Maintenance Organizations (HMO)/Alternative Financing Delivery System (AFSD)

• Numbers of Orders issued and the Carrier’s Position was Upheld: 84
• Number of Orders issued and the Carrier’s Position was Reversed:  42
• Cases Resolved before issuance of an Order: 23
• Not Accepted, Dismissed or Withdrawn: 146

—–

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PUBLIC NOTICE: The American Patient Defense Union Is Now Accepting Complaints From Patients Across the United States

www.medium.com/@patientdefenseunion/public-notice-the-american-patient-defense-union-is-now-accepting-complaints-from-patients-across-4f12ef06dbe1

Fellow Citizen,

This message is to inform you that The American Patient Defense Union is now open to receiving your personal complaints and grievances in interacting with Healthcare providers, insurers and drug/device companies.

Three categories of complaints will be considered by The Union:

1. Personal grievances about “process issues” at specific hospitals and practices.
2. Complications or allegations of harm at the hands of specific practitioners, hospitals or drug/device companies.
3. Personal financial difficulties, collection notices or bankruptcies caused by specific hospitals, practitioners or insurers.

Please limit your initial communication with The Union to a 500-word email submitted to complaints@patientrights.org. Please describe your grievance as concisely and specifically as possible. Following review and consideration of the information you provide, we will conduct a personal interview by phone in order to strategize with you. No communication with your providers or insurers will take place until we have conducted an interview and obtained your full consent to proceed. If you wish to communicate with us via a secure two-way encrypted email system, please create a free email account at protonmail.com and use it communicate with us.

Please note that The Union is strictly focused on individual patients’ specific and personal narratives of grievance or complication resulting from treatment by specific healthcare facilities, practitioners and drugs/devices in the United States. These can range from simple to complex matters.

The Union hopes to ultimately identify broad practices and policies that are causing financial or physical harm to individual patients across the United States — in order to address public policy issues on a larger scale. However, our strict starting point in all cases will be the individual American patient’s story of difficulties, conflict with or harm by specific practitioners, hospitals, insurers or drug/device companies.

The Union is NOT a law firm. However, in cases where we do believe negligence has occurred, we will recommend that you seek legal guidance.

We are aiming to defend your rights and voice, publicly —You, The American Patient.

The Union seeks to establish large-scale collective bargaining power capable of political lobbying at the state and federal levels with the goal of shifting medical practice in the United States away from a profit-driven corporate mode towards a patient-centered system. In achieving this goal, we need you to rise up and empower this union.

Please note that you are filing your complaint with The Union voluntarily. After verifying the information you provide, The Union will initially use this to generate a professionally-crafted and adequately-measured signal to the healthcare or insurance entity causing the grievance. This signal will be in the form of a letter of warning from The Union, to the entity you are interacting with, requesting immediate action on your behalf. Should the provider/insurer not respond in an adequate or timely fashion, this letter of warning will be shared with the public, the press and all members of The Union in order to maximize public scrutiny/exposure.

Ultimately, as The Union acquires member-driven power, it will provide the litigation services necessary to create changes to the behavior of our healthcare establishment using the individual grievances provided by our members.

Every Patient and citizen/resident of the United States is invited to join The Union. Specific instruction to join, including member fees, will be provided at www.patientrights.org in the near future.

Let’s begin to develop the powerful backbone every American patient needs to defend against harm in seeking a healthier tomorrow.

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https://youtu.be/97zzc_nuZgc

Filed under: General Problems | 1 Comment »

America’s Current Guidelines For Fixing The Opioid Crisis Will Increase Suffering And Death, Not Reduce It.

www.medium.com/@TheMeerkat/americas-current-guidelines-for-fixing-the-opioid-crisis-will-increase-suffering-and-death-not-8b4a21048430

Yesterday afternoon, President Trump declared America’s opioid crisis a public health emergency, and for good reason: the American Society of Addiction Medicine estimates that there’s nearly 2.6 million Americans with an opioid addiction, and the communities affected include some of our poorest and most vulnerable. The problem is becoming critical, and solving it goes beyond politics to become one of basic human compassion.

The only problem: current guidelines by the FDA and CDC are ineffective, based on a factually‐faulty premise unsupported by evidence, and will almost certainly increase suffering and death without significantly improving the numbers for opioid addiction.

Let’s focus on “ineffective” first.

Current Guidelines

FDA Commissioner Scott Gottlieb has put out a statement affirming that they “have an important role to play in addressing the crisis, particularly when it comes to reducing the number of new cases of addiction”:

Patients must be prescribed opioids only for durations of treatment that closely match their clinical circumstances and that don’t expose them unnecessarily to prolonged use, which increases the risk of opioid addiction. Moreover, as FDA does in other contexts in our regulatory portfolio, we need to consider the broader public health implications of opioid use. We need to consider both the individual and the societal consequences.

(For this, and all future quotes, all bolding is my own emphasis.)

The CDC goes further with its current guidelines, including a clinical “reminder” that “opioids are not first-line or routine therapy for chronic pain”. It recommends to use as low of a dose as possible for as short of a time as possible, frequently reconsider its upkeep, and to only start them as a last result.

Almost any statement made by public officials relating to the crisis is based on the same two premises: reducing the number of patients receiving long‐term opioid prescriptions is the most effective way to curtail the opioid epidemic, and most opioid addictions start as a result of use that began as legitimate.

Unfortunately, nearly all the evidence we currently have contradicts these foundations. If you’re interested in a detailed, academic look at the topic, there’s a fantastic article written by three doctors — including an Associate Professor at the University of Massachusetts Medical School — appropriately titled “Neat, Plausible, And Generally Wrong”:

Recommendations from the Centers for Disease Control and Prevention (CDC) for chronic opioid use, however, move away from evidence, describing widespread hazards that are not supported by current literature. This description, and its accompanying public commentary, are being used to create guidelines and state-wide policies.

These recommendations are in conflict with other independent appraisals of the evidence — or lack thereof — and conflate public health goals with individual medical care. The CDC frames the recommendations as being for primary care clinicians and their individual patients. Yet the threat of addiction largely comes from diverted prescription opioids, not from long-term use with a skilled prescriber in a longitudinal clinical relationship. By not acknowledging the role of diversion — and instead focusing on individuals who report functional and pain benefit for their severe chronic pain — the CDC misses the target.

We need to break some statistics down. According to the 2014 National Survey on Drug Use and Health, 74.9% of nonmedical opioid use happens as a result of people taking medication they were not prescribed, such as those obtained or stolen from a friend or drug dealer. A further 3.1% fraudulently obtained prescriptions from multiple doctors, a practice called “doctor‐hopping”. That’s a total of 78% of sources other than a relationship with a single doctor. That leaves 22% of those who were addicted who do receive their pills from a doctor, but we need to put that number into perspective.

A Cochrane review of opioid use in chronic non‐cancer pain found that fewer than one percent of people who were responsibly prescribed opioids developed an addiction.

The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well-selected patients with no history of substance addiction or abuse can lead to long-term pain relief for some patients with a very small (though not zero) risk of developing addiction, abuse, or other serious side effects.

Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome.

A scant 0.27% of patients prescribed long‐term opioids for chronic pain showed signs of becoming addicted. The doctors above found similarly‐low rates of addiction with other sources of data.

 

Part of responsible prescribing involves screening patients for their addiction risk. Though physicians tend to report a low confidence in this field, a pilot study in the Journal of Pain and Symptom Management found that it’s far easier than one would expect to find which patients are genuine, and the results have been repeated since.

Responses of addicted patients significantly differed from those of nonaddicted patients on multiple screening items, with the two groups easily differentiated by total questionnaire score. Further, three key screening indicators were identified as excellent predictors for the presence of addictive disease in this sample of chronic pain patients.

It’s important to recognize that scripts written properly aren’t the cause of the epidemic, because — beyond being ineffective — this mindset can actually lead to reduced access to treatment for those with addictions.

Buprenorphine is an opioid that’s used as maintenance therapy, as it has a far lower risk of causing respiratory depression, the primary killer in opioid overdose. Its use as a maintenance therapy is associated with a significantly lower chance of death than leaving addiction untreated; inexplicably, however, the use of buprenorphine was stifled by a 2000 law stating that only 30 patients could be treated at any one time per physician to begin with, and only after jumping through numerous bureaucratic hoops that made it more difficult to prescribe treatment for opioid addiction than the opioids themselves.

[As of June 2017,] only 35,894 providers are currently eligible to prescribe buprenorphine for addiction. Of those 35,894 only about 1/3 actively prescribe the treatment; and these few are further limited by the patient caps.

 

Prescriptions, given to patients adequately screened by and in possession of a good relationship with the physician, and used by the patient for which they were prescribed, simply are not the cause of the majority of opioid use disorders — diverted prescriptions and irresponsible mass scripts from so‐called “pill mills” are. You may have heard the small West Virginian town of Kermit mentioned in the news recently due to one of their drugstores: “In just two years, drug wholesalers shipped 9 million opioid pills to a pharmacy in Kermit, WV, a town of just 400 people.”

Researchers logged nearly 1,000 cases of doctors being either charged or administratively reviewed for the inappropriate prescription of opioid drugs over an eight year period, and specific high‐profile cases have been the subject of numerous documentaries. Pill mills prey on those susceptible to addiction, and prescribe indiscriminately:

Like the other pain clinics in Portsmouth where Volkman had worked, the clinic only accepted cash — no insurance, no Medicaid. In exchange for $150, patients could expect to receive high doses of pain medications, anti-anxiety agents, and muscle relaxers. In September 2005, according to a search warrant, one Portsmouth Police informant stopped in to see Volkman and received prescriptions for 180 oxycodone pills, 180 Lorcet (a hydrocodone-based painkiller) pills, 120 Soma (a muscle relaxer) pills, and 90 Xanax. Two days later, another informant received a prescription for 270 oxycodone pills, 270 Percocet, 120 Somas, and 60 Xanax. Volkman’s clinics brought in thousands of dollars in cash and pumped out thousands of pills in a region that was already being described in the Portsmouth Daily Times as “The OxyContin Capital of the World.”

Pill mills have become as much an epidemic as the problem they have, in large part, caused, and their existence is supported by the for‐profit pharmaceutical companies that manufacture the opioids; in 2016, the pharmaceutical industry spent over $246M dollars lobbying lawmakers to, among other things, enfeeble the DEA’s ability to go after improper drug distributors, and it’s not slowing down. At the time of this article’s publication, over $208M has been spent by the industry thus far in 2017.

It’s an operation driven by profit from the top down, and it’s easy to see how backing the CDC’s position of cracking down on opioids entirely becomes tempting, but there are ways to curtail excessive prescriptions without creating a devastating case of throwing the baby out with the bathwater.

According to the American Pain Society, there are over 25 million Americans who experience daily chronic pain — pain that affects quality of life every single day. Conditions like lupus, fibromyalgia, Ehlers‐Danlos syndrome, various forms of arthritis, and many more cause pain that is not only severe, but unending. That’s an important number, because it’s just about ten times the number of patients with an opioid addiction.

I’ve made two separate claims: increased suffering, and increased deaths. I’ll start with suffering.

 

“But Have You Tried Yoga?”

Invariably, you’ll find guidelines instructing doctors to tell patients to pursue “alternative” painkilling strategies first, as if there are myriad wells of untapped relief that chronic pain patients simply ignore.

There aren’t.

We can save time and start with the easy ones: acupuncture doesn’t work. There’s some evidence for massage being somewhat effective for some conditions, but the fact that it’s rarely covered by insurance and the need for ongoing treatment renders the cost/benefit ratio bad. Marijuana is still federally illegal, unavailable in many states, and its presence on a drug test still precludes many employment opportunities for pain sufferers who are able to work. Chiropractic is ineffective pseudoscience that hurts more than it helps. Supplements can cause harm, interact with real medicine, and extraordinarily few have any high‐quality evidence for any condition, including almost none for chronic pain.

That leaves the big one: exercise. “Exercise helps reduce chronic pain!” is repeated often and adamantly, as if it is long‐accepted fact that has a long, positive background in research. Does it?

As recently as April of this year, Cochrane looked over twenty‐one of their reviews of studies regarding exercise for chronic pain, and found that the evidence was generally insufficient:

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.

There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.

[…]

Additionally, participants had predominantly mild-to-moderate pain, not moderate-to-severe pain.

Beyond that, the correlation between chronic pain and chronic fatigue is massive, with everything from lupus and fibromyalgia to EDS, rheumatoid arthitis, and Raynaud syndrome causing heavy fatigue, and that in no way comprises a complete list. Despite what the CDC incorrectly insisted for years past being proven inaccurate, exercise invariably makes chronic fatigue, such as found in CFS, worse.

So strike all the chronic pain patients suffering from chronic fatigue. Of the remainder, what about the ones with a strong medical reason not to exercise? Chronic pain caused by physical damage, Ehlers‐Danlos patients unable to exercise or maintain yoga‐esque positions due to frequent joint dislocations, inflammatory conditions that forbid normal ranges of movement, those with heart conditions exacerbated by activity…

We’re left with a small slice of the pie chart for which exercise gets the chance to be effectively used at all, and I would posit that even if there was evidence for it, calling it a replacement for pain management and not something to do alongside it is an act of cruelty. This was stated earlier, but it necessitates repeating: chronic pain is daily. Chronic pain causes real suffering every day, and frequently every hour.

There are no “good days” where you don’t have pain, just days that are “somewhat better than usual”. Imagine this: every day, anywhere from “many parts” to “every part” of your body hurt; unrelenting, bone‐deep aching, nerves that light themselves on fire, jabbing pain coursing through your muscles upon the slightest activity.

If your pain levels average out to 7/10 on a daily basis, would you intentionally up the pain to 9/10 numerous days a week just to — after weeks and months of agony — potentially bring that daily average down to 6/10? Would you feel like you got good value on that proposition? Would you consider it worth it? Would you have the will to keep it up every week until your death, forever? It doesn’t matter if we assume the unsubstantiated claims of notable improvement are true; would you not want pain relief for the days in which your suffering was greatly increased?

Pain needs to be managed, and there are, unfortunately, limited ways to effectively do so. The single most efficacious non-pharmaceutical treatments involve mental mechanisms, such as mindfulness meditation and CBT, which do nothing to reduce the pain itself — merely one’s perception of it. They help, but they can take months to see improvement, and will always leave you with a certain baseline of pain that needs to be treated through some other avenue.

 

The End Of The Road

Depression affects up to half of all chronic pain patients. According to studies, risk of suicide is at least double that of controls, with up to 14% of CPP attempting suicide and around 20% of them experiencing suicidal ideation. Causes and levels of chronic pain can be disabling and prevent patients from maintaining gainful employment, or from participating in the hobbies and activities that were once important to them.

Chinese water torture is a process in which water is slowly dripped onto a person’s forehead, allegedly making the restrained victim insane.

The comparison might seem trite, but it’s apropos: the worst part of chronic pain is not the “pain” — it’s the “chronic”. Relentless pain dominates your life in a way few healthy people appreciate. It demands schedules to be built around it; it demands plans to be canceled en masse when it unexpectedly flares; it holds you as a hostage in your own body and taunts you with its permanency. Make no mistake that even with opioids, it makes it more manageable, not absent; completely eliminating pervasive pain is nearly impossible.

If relief is taken away from chronic pain sufferers indiscriminately and under faulty pretenses, the question is not whether it will result in increased disability and suicide — the question is only by how much.

The opioid crisis needs solutions, and quickly, but it also needs those solutions to be factual, effective, and compassionate, and our current theories for how opioid addiction starts and how it needs to end are none of the above.

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Pain doctor testifies at Christensen trial

http://ravallirepublic.com/news/local/article_7f3b1088-f8f7-5f52-8da9-6950748122c7.html

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